Usefulness of a hypertension education program.Background: Our objective was to assess knowledge about hypertension, its medical consequences in hospitalized patients with hypertension and in their relatives, and to evaluate the usefulness of a simple education program to improve such knowledge. Method: As part of a cohort study A cohort study is a form of longitudinal study used in medicine and social science. It is one type of study design. In medicine, it is usually undertaken to obtain evidence to try to refute the existence of a suspected association between cause and disease; failure to refute , six clinical physicians reviewed the medical charts of all hospitalized patients in the departments of medicine, general surgery, and orthopedic surgery Orthopedic Surgery Definition Orthopedic (sometimes spelled orthopaedic) surgery is surgery performed by a medical specialist, such as an orthopedist or orthopedic surgeon, trained to deal with problems that develop in the bones, joints, and ligaments . Patients with the antecedent ANTECEDENT. Something that goes before. In the construction of laws, agreements, and the like, reference is always to be made to the last antecedent; ad proximun antecedens fiat relatio. of hypertension, patients without the antecedent of hypertension but with at least two measurements of blood pressure above normal limits during hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun) 1. the placing of a patient in a hospital for treatment. 2. the term of confinement in a hospital. , and the relatives or friends who were accompanying patients with known or unknown hypertension were included. Patients received an education program about hypertension. Knowledge about hypertension and its complications was assessed on the basis of three items before the education program and 4 months later. Results: A total of 102 patients entered the study and 95 completed it. An association was found between higher education higher education Study beyond the level of secondary education. Institutions of higher education include not only colleges and universities but also professional schools in such fields as law, theology, medicine, business, music, and art. level and knowledge about hypertension; differences were significant with two of the three employed items (P < 0.005). Compared with baseline, knowledge about hypertension was improved 4 months after the education program; differences were significant with the three employed items (P < 0.005). Conclusions: Simple and easy-to-implement programs can be useful in improving knowledge about hypertension. Key Words: education programs, hypertension, knowledge ********** Hypertension is one of the most common health problems affecting people in developed countries. If left untreated, hypertension has serious consequences in the cardiovascular system cardiovascular system: see circulatory system. cardiovascular system System of vessels that convey blood to and from tissues throughout the body, bringing nutrients and oxygen and removing wastes and carbon dioxide. , whereas an adequate treatment has been demonstrated to substantially decrease morbidity and mortality Morbidity and Mortality can refer to:
Effects of a proposed project on other parts of the firm. , lack of concern about the risks of hypertension, and poor patient-physician relationship patient-physician relationship Medtalk A formal relationship that exists between the physician and the Pt, often equated to medical 'duties' that the physician must perform in a professionally acceptable manner. See Doctor-Pt interaction. Cf Abandonment. . (8) The determinants of nonadherence are involved and difficult for physicians to understand (9) and different factors are often present simultaneously in one patient. (10) (11) Deficient knowledge about hypertension and its clinical consequences is another important determinant of nonadherence. (12) (13) Moreover, education programs have proven useful, not only to improve adherence to antihypertensive antihypertensive /an·ti·hy·per·ten·sive/ (-ten´siv) counteracting high blood pressure, or an agent that does this. an·ti·hy·per·ten·sive adj. Reducing high blood pressure. n. therapy but also to adequately control high blood pressure. (3) (14-16) In this study, we assessed knowledge about hypertension and its medical consequences in hospitalized patients with hypertension, and in their relatives, and evaluated the usefulness of a simple education program to improve such knowledge. In addition, we evaluated adherence to treatment and the determinants of nonadherence in the subset of patients who had hypertension and were taking antihypertensive medications. Methods Study Design and Patients This cohort study was performed in the General Hospital of Castellon, Spain, a tertiary care center tertiary care center Hospital care A hospital or medical center for Pts often referred from secondary care centers, which provides subspecialty expertise Tertiary care center Surgery . During a 3-week period, patients were recruited as follows: the medical charts of all hospitalized patients in the departments of medicine, general surgery, and orthopedic surgery were reviewed by six clinical physicians. Patients with the antecedent of hypertension were selected for the study as "patients with known hypertension" (PKH PKH Peter Knipp Holdings (Singapore) ). According to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. established criteria for the diagnosis of hypertension, (17) patients without the antecedent of hypertension, but with at least two measurements of blood pressure equal to or above 140 mm Hg systolic Systolic The phase of blood circulation in which the heart's pumping chambers (ventricles) are actively pumping blood. The ventricles are squeezing (contracting) forcefully, and the pressure against the walls of the arteries is at its highest. or 90 mm Hg diastolic Diastolic The phase of blood circulation in which the heart's pumping chambers (ventricles) are being filled with blood. During this phase, the ventricles are at their most relaxed, and the pressure against the walls of the arteries is at its lowest. during hospitalization, were informed about their condition and were selected for the study as "patients with unknown hypertension" (PUH). Finally, the relatives or friends who were accompanying both PKH and PUH when first surveyed were also selected for the study as "accompanying persons" (AP). All three patient groups were offered the opportunity to participate in the study, after a brief explanation of it. Baseline Sociodemographic and Hospitalization Variables At enrollment, the following data were obtained from each patient: age, sex, place of residence (urban or rural), living conditions living conditions npl → condiciones fpl de vida living conditions npl → conditions fpl de vie living conditions living (alone or with someone else), education level (high, intermediate, elementary, or none), smoking habit or not, number of medications taken each day, department of hospitalization (medical or surgical), and physician who surveyed the patient. Knowledge of Hypertension and Education Program After enrollment, all patients were questioned to determine if they knew the following three concepts about hypertension: 1) the normal blood pressure limits (below 140 mm Hg systolic and 90 mm Hg diastolic); 2) that hypertension may be asymptomatic a·symp·to·mat·ic adj. Exhibiting or producing no symptoms. Asymptomatic Persons who carry a disease and are usually capable of transmitting the disease but, who do not exhibit symptoms of the disease are said to be ; and 3) the major complications of hypertension. All answers were noted as right or wrong. Afterward, all patients received a 15-minute explanation about hypertension, including definition, clinical manifestations, complications, and treatment. Each patient was also provided with an explanatory brochure to reinforce the same information. Patients could ask questions about hypertension, which were answered by the clinical physicians who were conducting the study. Adherence to Treatment Regimen The following data were recovered from PKH: time elapsed e·lapse intr.v. e·lapsed, e·laps·ing, e·laps·es To slip by; pass: Weeks elapsed before we could start renovating. n. since the diagnosis of hypertension, presence or absence of stress provoked by being concerned about high blood pressure at the time of diagnosis of hypertension, and last prescribed treatment (pharmacologic pharmacologic /phar·ma·co·log·ic/ (-kah-loj´ik) pertaining to pharmacology or to the properties and reactions of drugs. pharmacological, pharmacologic pertaining to pharmacology. or nonpharmacologic). Adherence was assessed in the subset of patients who were taking antihypertensive medications. For that purpose it was first determined if patients knew the trade name of their antihypertensive treatment and the number of daily doses of antihypertensive medications that had been prescribed for them. After a brief explanation about the difficulties of correctly taking medications on a long-term basis, patients were asked to report the overall percentage of doses of medication that they had taken during the previous 3 months and the reasons why they had not taken them (side effects, supposed lack of efficacy, supposed irrelevance ir·rel·e·vance n. 1. The quality or state of being unrelated to a matter being considered. 2. Something unrelated to a matter being considered. Noun 1. of uncontrolled hypertension, simply forgetting, being away from home, shortage of medication, or other). Follow-up After completing the education program, consent was obtained from all patients to participate in a second part of the study 4 months later. At that time, via a telephone call, patients' knowledge about hypertension, and adherence to medications if appropriate, were reassessed with the same questionnaires that had been employed at baseline. Statistical Analysis A sample size of 98 patients was calculated to detect a 12% difference in knowledge about hypertension between baseline and 4 months later, with a [beta] error of 0.10, at the [alpha] level of 0.05, taking into account that 5% of patients would be lost to follow-up. Logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. was used to assess the possible association of sociodemographic and hospitalization data with baseline knowledge about hypertension. A linear regression Linear regression A statistical technique for fitting a straight line to a set of data points. model was used to assess the possible association of sociodemographic, hospitalization, knowledge about hypertension, and adherence variables with self-reported adherence. The McNemar test was used to assess possible differences between baseline and 4 months in knowledge about hypertension. The Wilcoxon signed ranks test was used to evaluate possible differences between baseline and 4 months in self-reported adherence. When comparing two subgroups of patients, differences in continuous variables were analyzed using a t test or a Wilcoxon rank-sum test, and differences in categorical data categorical data data relating to category such as qualitative data, e.g. dog, cat, female. It may be nominal when a name is used, e.g. location, breed, or ordinal when a range of categories is used, e.g. calf, yearling, cow. were analyzed using a [chi square chi square (kī), n a nonparametric statistic used with discrete data in the form of frequency count (nominal data) or percentages or proportions that can be reduced to frequencies. ] test or a Fisher's exact test Fisher's exact test a statistical test for association in a two-by-two table based on the exact hypergeometric distribution of the frequencies within the table. . All reported P values were two-sided, with a significance level of 0.05. Results Baseline A total of 241 medical charts were reviewed; 60 (25%) belonged to patients with hypertension. Those patients along with 42 AP were offered the opportunity to participate in the study; all of them (n = 102) accepted voluntarily. Table 1 shows their sociodemographic and hospitalization characteristics. Compared with hypertensive hypertensive /hy·per·ten·sive/ (-ten´siv) 1. characterized by increased tension or pressure. 2. an agent that causes hypertension. 3. a person with hypertension. patients, APs were younger, more commonly female, more commonly lived with someone else, took fewer medications, and had higher education levels. Of the 60 patients with hypertension, 51 (85%) were PKH and 9 (15%) were PUH. The sociodemographic characteristics of PUH were not particularly different than those of PKH. Table 2 displays the evaluation of knowledge about hypertension. At baseline, multivariate analysis multivariate analysis, n a statistical approach used to evaluate multiple variables. multivariate analysis, n a set of techniques used when variation in several variables has to be studied simultaneously. disclosed the following associations: correct answer to question 1 with being hospitalized in surgical (versus medical) department (P = 0.0022) and with higher education levels (P = 0.0002); correct answer to question 2 with being hospitalized in surgical (versus medical) department (P = 0.0000); and correct answer to question 3 with urban residency (P = 0.0253) and with higher education levels (P = 0.0010). No association was found between the other sociodemographic and hospitalization variables. In the 51 PKH, the median time elapsed since the diagnosis of hypertension was 10 years; 30 of these patients (59%) reported that they were stressed when they first received the diagnosis of hypertension. Of the 51 PKH, 48 (94%) had been prescribed medications for hypertension, and 3 (6%) had been prescribed only diet modifications and no medications. Of the 48 patients who were on antihypertensive drugs Antihypertensive Drugs Definition Antihypertensive drugs are medicines that help lower blood pressure. Purpose The overall class of antihypertensive agents lowers blood pressure, although the mechanisms of action vary greatly. , 19(40%) did not know the trade name of their antihypertensive medication; 32 (67%) reported that they had been prescribed a daily antihypertensive, 11 (23%) had been prescribe two or more daily doses, and 5 (10%) did not know how many doses had been prescribed. Of those 48 patients, 31 (65%) reported 100% adherence, 8 (17%) reported 90 to 99% adherence, 6 (12%) reported 50 to 89% adherence, and 3 (6%) reported 0 to 49% adherence. The main reasons for nonadherence were simply forgetting in 8 patients (17%), being away from home in 3 (6%), and shortage of medications in 3 (6%). No association was found between adherence and sociodemographic, hospitalization, knowledge about hypertension, or adherence variables. Follow-up at 4 Months At 4 months, reassessment Reassessment The process of re-determining the value of property or land for tax purposes. Notes: Property is usually reassessed on an annual basis. You may request a "reassessment" if you disagree with your assessment. of knowledge about hypertension could be carried out in 95 patients (93%). Three patients had died, three more were ill and declined to take part in the study at that time, and one patient could not be contacted. Table 2 summarizes the results, which shows an improved knowledge at 4 months, as measured with any of the three items employed in the study. Of the 48 patients with hypertension who were assessed at baseline, 46 could be reassessed at 4 months. One patient had died and another one could not be contacted. Of those 46 patients, 13 (28%) did not know the trade name of their antihypertensive medication; 30 (65%) reported that they had been prescribed a daily antihypertensive, 13 (28%) had been prescribed two or more daily doses, and 3 (6%) did not know how many doses had been prescribed. Of those 46 patients, 31 (67%) reported 100% adherence, 12 (26%) reported 90 to 99% adherence, and 3 (6%) reported 50 to 89% adherence. The main reasons for nonadherence were simply forgetting in 8 patients (17%), being away from home in 3 (6%), and side effects in 2 (4%). Knowledge of the trade name of the medications and self-reported adherence were higher at 4 months compared with baseline, but differences were not significant. Key Points * Adequate control of hypertension is essential in preventing cardiovascular diseases Cardiovascular disease Disease that affects the heart and blood vessels. Mentioned in: Lipoproteins Test cardiovascular disease . * Knowledge about hypertension facilitates adherence to treatment and improves adequate control of blood pressure. * Knowledge about hypertension is inadequate in the general population, especially in those with lower education levels. * Simple and easy-to-implement programs can be useful in improving knowledge about hypertension. Discussion The results of our study underline underline an animal's ventral profile; the shape of the belly when viewed from the side, e.g. pendulous, pot-belly, tucked up, gaunt. the well-known fact that hypertension remains undiagnosed in many patients, even in developed countries. (12), (18) By simply reviewing 241 medical charts, we were able to detect nine hospitalized patients who were unaware of their condition. A multivariate analysis of our data demonstrated that the most consistent predictor of knowledge about hypertension was the high education level of patients. Another study carried out in our area found an association of knowledge about hypertension with income level but not with education level. (12) Being hospitalized in a surgical department was also associated with having better knowledge about hypertension. We found no reason to explain this association. Nonadherence to treatment is a problem of striking magnitude with any chronic disease. (19) Measurement of adherence is imperfect and lacking a gold standard. Patients' self-reports tend to overestimate o·ver·es·ti·mate tr.v. o·ver·es·ti·mat·ed, o·ver·es·ti·mat·ing, o·ver·es·ti·mates 1. To estimate too highly. 2. To esteem too greatly. adherence but, when patients are asked in a nonjudgmental non·judg·men·tal adj. Refraining from judgment, especially one based on personal ethical standards. Adj. 1. nonjudgmental manner, they generally tell the truth and this method has proven useful in clinical practice. (2), (8), (20) With this technique we found unacceptably high levels of nonadherence, although they were similar to those reported in other studies. (21), (22) Significant percentages of patients did not know relevant details about their antihypertensive medications, such as trade names or daily doses that they had been prescribed, which suggests lack of motivation to adhere to adhere to verb 1. follow, keep, maintain, respect, observe, be true, fulfil, obey, heed, keep to, abide by, be loyal, mind, be constant, be faithful 2. treatment. Simply forgetting was the main reported reason for non-adherence in our patients. There are few studies assessing the causes of nonadherence to antihypertensive medications as reported by patients, with discrepant dis·crep·ant adj. Marked by discrepancy; disagreeing. [Middle English discrepaunt, from Latin discrep results among them. (21), (23) In other chronic illnesses, simply forgetting has also been identified as a prevalent cause of nonadherence. (24) Reassessment of knowledge about hypertension 4 months after initial evaluation showed better results than at baseline. This demonstrates that a simple education program can significantly improve knowledge about hypertension in patients with that condition and also in their relatives or APs. Another study carried out in hospitalized patients with hypertension also demonstrated the usefulness of this kind of program. (14) Similar education programs have proven to be valuable as well in nonhospitalized patients with hypertension and other cardiovascular risk factors. (25) (26) Self-reported adherence was also better at 4 months than at baseline; nevertheless the study had not been powered to compare adherence, and differences were not significant. Other studies have successfully demonstrated that enhanced knowledge about hypertension can improve not only adherence to treatment but also provide adequate control of blood pressure. (3), (12), (14), (15), (27), (28) To reduce cardiovascular morbidity and mortality, education programs designed to improve knowledge about hypertension and its clinical consequences are needed, especially among people of lower socioeconomic status socioeconomic status, n the position of an individual on a socio-economic scale that measures such factors as education, income, type of occupation, place of residence, and in some populations, ethnicity and religion. . Simple and easy-to-implement programs, like the one employed in this study, can be very useful for that purpose. A hammer strikes a rock fifty times, Without a crack appearing. On the fifty-first blow, the rock splits. This blow alone didn't split the rock, But also all those blows that went before it. --Mark Link
Table 1. Epidemiological characteristics of participants
Characteristic Patients with
hypertension (a)
No. of patients 60
Age (yr), mean [+ or -] SD 71 [+ or -] 13
Female sex (%) 30 (50)
Urban residency (%) 35 (58)
Living with someone else (%) 50 (83)
Education level intermediate or high (%) 5 (8)
Smoker (%) 12 (20)
Number of medications taken every day, median 4
Medicine (versus General Surgery and 41 (68)
Orthopedic Surgery) Department (%)
Characteristic Accompanying P
people
No. of patients 42 -
Age (yr), mean [+ or -] SD 55 [+ or -] 15 0.000
Female sex (%) 38 (90) 0.000
Urban residency (%) 21 (50) 0.529
Living with someone else (%) 41 (98) 0.022
Education level intermediate or high (%) 11 (26) 0.015
Smoker (%) 10 (28) 0.645
Number of medications taken every day, median 1 0.000
Medicine (versus General Surgery and 31 (74) 0.550
Orthopedic Surgery) Department (%)
(a) Includes patients with known hypertension (PKH) and patients with
unknown hypertension (PUH)
Table 2. Number and percentage of individuals whose knowledge of
hypertension was accurate
Item Evaluated Baseline 4 months
no. concept (n = 102) (n = 95) P
1 Normal blood pressure 35 (34) 49 (52) 0.002
limits
2 Hypertension may be 45 (44) 66 (69) 0.000
asymptomatic
3 Major complications 61 (60) 77 (81) 0.001
of hypertension
From the Department of Medicine, General Hospital of Castellon, Castellon, Spain. Reprint reprint An individually bound copy of an article in a journal or science communication requests to Bernardino Roca, MD, Catalunya, 33-A, 4, 12004 Castellon, Spain. Email: brocav@meditex.es Accepted October 1, 2002. Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9611-1133 References 1. Kannel WB. Risk stratification risk stratification Medical decision-making The constellation of activities–eg, lab and clinical testing used to determine a person's risk for suffering a particular condition and need–or lack thereof–for preventive intervention in hypertension: New insights from the Framingham Study. Am J Hypertens 2000;13:3S-10S. 2. Wood D. The treatment potential in preventive cardiology cardiology Medical specialty dealing with heart diseases and disorders. It began with the 1749 publication by Jean Baptiste de Sénac of contemporary knowledge of the heart. 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Konrady AO, Brodskaya IS, Soboleva AV, Polunicheva YV. Benefits of the implementation of structured educational program in hypertension management. Med Sci Monit 2001;7:397-402. Bernardino Roca, MD, PHD, Elena Nadal, MD, Rosa E. Rovira, MD, Sonia Valls, MD, Consol Lapuebla, MD, and Nestor Lloria, MD |
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